Because of the difficult learning curve associated with hip arthroscopy and limited exposure to cases during residency training, alternative training options such as cadaveric skills labs and arthroscopic simulator training should be explored (Fig. 20.1). These methods offer an environment in which the nascent hip arthroscopist has the opportunity to learn and practice valuable skills without exposing a patient to potential harm or consuming valuable time in the operating room. A systematic review of arthroscopic simulator training studies concluded that training on knee simulator improves performance on simulators, but could not definitively establish that such training improves skill in the operating room [29]. However, a number of studies in the general surgery literature have demonstrated the transfer validity of simulator training to surgical procedures [15–17]. Although the orthopedic literature is more limited, there is evidence that arthroscopy simulation training likewise translates to improved technical ability in the operating room. Cannon et al. demonstrated the transfer validity of arthroscopic simulation in a randomized study of orthopedic residents trained on a virtual knee simulator [18]. Postgraduate year 3 orthopedic residents at seven institutions were randomized into simulator-trained and control groups. Simulator-trained residents were trained in knee diagnostic arthroscopy using the ArthroStim^TM (Touch of Life Technologies, Aurora, Colorado) virtual-reality arthroscopic knee simulator an average of 11 h. Both groups then performed a diagnostic knee arthroscopy procedure on a live patient and were evaluated by expert arthroscopists who were blinded to the residents’ identities. Simulator-trained residents were found to perform significantly better in the operating room than their peers when rated according to an internal procedural checklist. Howell et al. also found significant improvement in psychomotor skills in a randomized study of junior orthopedic residents who were trained on a benchtop knee arthroscopy simulator. This again translated to superior performance in the operating room on an actual patient.

Arthroscopic hip simulators are relatively new and have not been as well studied as those for the knee and shoulder in orthopedic education. One such device is the Sawbones® (Malmo, Sweden) hip arthroscopy simulator (Fig. 20.2). [30, 32] used this simulator to train residents in hip arthroscopy, studying differences in learning curve patterns for residents trained in supine versus lateral positions. Subjects were assessed using 3D motion analysis, using the parameters of time taken to perform the procedure, number of hand movements, and total path length of hand movements. Residents were noted to have a learning curve similar to those established in studies of laparoscopic procedures and arthroscopy of the knee and shoulder. Subjects in both groups demonstrated significant objective improvement in all parameters, which appeared to plateau after nine training sessions. Those trained in the lateral position initially encountered more difficulty, which the authors surmised was due to disorientation, but rapidly achieved parity with the supine group. Junior trainees were also found to perform at a similar level to more senior trainees by the end of the study period. While the evidence is limited, these studies suggest that simulator training improves technical skill that is transferrable to the operating room and may present a supplemental avenue for training hip arthroscopists.

Although the literature is limited on how hip arthroscopy and FAI surgery is or should be taught, teaching to the appropriate level is important. This too depends on whether a resident partakes in any hip arthroscopy at all or participates and becomes competent. Further, difficulties exist in standardizing education, as differences exist internationally with regard to exposure [24]. Resident education may benefit from teaching technical steps in a stepwise progression, beginning with patient positioning and use of traction and progressing to joint access, capsulotomy, rim preparation, labral and chondral work, femoral work, and capsule work [30, 31]. Such a progression might allow trainees to absorb and emulate the technical aspects of FAI treatment in a reproducible fashion. Some opt for a standardized technique such as the 23-point hip arthroscopy procedure which may allow easier teaching and standardization for those learning the technique [31]. This is difficult, however, because no standardized techniques exist as there is great variability, for example, in hip arthroscopy access and number of portals used, if capsulotomy is done and if the capsule is closed.